An Inside Job: Best Practices from Within

The best solutions to an organization’s problems may be found among its members.

Many organizations must wrestle with the challenge of how to identify best practices and ensure their effective implementation. In 2001, the Veterans Health Administration Pittsburgh Healthcare System (VAPHS) faced such a situation: The number of patients contracting preventable hospital-acquired infections at these facilities was increasing at an alarming rate. Although the solution — better hygiene — seemed simple, actually changing staff behavior in the complex hospital environment was a daunting task.

In search of a new organizational framework to confront the problem, VAPHS’s management turned to experts trained in the Toyota production system (TPS). For three years, the TPS team worked to uncover systemic problems and standardize procedures. By some metrics, the approach worked. In both the surgical ward and intensive care unit at the University Drive facility where the team of experts introduced TPS, the staff addressed a few of the obstacles, including mismanagement of supplies that thwarted sanitary protocols, and infection rates dropped by 70 percent. But their success was limited. Even after significant investments in time, money, and outside expertise, the new practices — although successful in the two units — failed to trickle down to the rest of the units in the hospital that needed similar improvements.

Having tried outside consultants, management decided to switch gears after one of the hospital’s surgeons happened to read an article on a strategy called Positive Deviance (PD). This method, which has been used to combat malnutrition in Vietnam, is based on the idea that within any community or organization there are members whose unique behaviors let them find solutions to problems that most other people find difficult to address. Unlike TPS and familiar problem-solving methods, PD assumes the community already knows what needs to happen; it’s just a matter of finding the people who have the best ideas and encouraging them to spread those ideas.

For the Pittsburgh VA hospitals, the change in direction was exactly what was needed. Using PD in two facilities — University Drive and the H.J. Heinz III Center — management discovered dozens of staff-driven solutions to reduce the spread of bacteria, and infection levels dropped by 50 percent. But even more important, PD succeeded in causing a sea change. The solutions spread hospital-wide. Personnel at all levels adopted a culture of collective responsibility, and now identifying best practices isn’t limited to once-a-year evaluations — it happens every day.

Although within different organizations the exact process may vary, every PD program begins by letting the community be the experts. By shifting the responsibility away from outside consultants and top-level managers, the staff is more likely to take ownership of problem-solving methods. This is especially important in organizations, such as hospitals, where a rigid hierarchy normally dictates staff interactions. One of the chief complaints about TPS from management at the Pittsburgh facilities was a low level of staff involvement, because the program depended almost entirely on the TPS experts to function. In contrast, under the PD method, collective brainstorming sessions meant everyone from janitors to physicians came forth to share suggestions and ideas. That mentality remains. John Lloyd, a retired surgeon who now coordinates infection prevention for the Pittsburgh VA system, points out that in the past if you asked people to identify who was responsible for preventing the spread of infections they looked to the infection control physician. Recently management asked the same question at an all-hands meeting involving hundreds of staff and they all raised their hands.

The first task is to bring together staff from all levels to brainstorm solutions and identify the Positive Deviants, or the individuals among the group who are finding ways to work around problems by deviating from standard practices. Discussions at the hospital revealed that even before PD was introduced, certain staff members were already implementing best practices in creative ways. For example, one attendant incorporated hand sanitization into her patients’ evening entertainment activities. No one else had stopped to think that communal items like board games and TV remotes were facilitating the spread of bacteria.

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